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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLEINFORMATION <br /> Vehicle Name (DBA): T <br /> Address for Vehicle: <br /> treet Address city <br /> 1) License Plate#: 4 S � q '� _ 4) Year: <br /> 2) Vehicle Vin #: + (�� 5) Make/Model: vY I <br /> 3) State Decal #: r1 6) Color: <br /> VEHICLE_OWNER INFORMATION <br /> Name: <br /> Address of Owner: C l —) !✓ Y ; '�/ <br /> Street Address city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office may result in permit revocation and penalties. <br /> Signa ure of Vehicle Operator Date <br /> COMMISSARY INFORMATION, <br /> G r <br /> Business Name:,, T ;1 <br /> Owner Name: <br /> Site Address: c. `G1 <br /> { Street Address r city <br /> Phone: (jj)".`] f ` 7-- /- <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> U�juid&solid waste disposal ,Utensil washing sink ❑ Store frozen food D-Ve-hicle wash facilities <br /> (2 oar 3 compartments) <br /> reparation of food blot&c water for cleaning [D-T oilet&hand washing ❑ Store refrigerated food <br /> Store dry-food/supplies [P"rovide potable water ❑-ci'vernight parking Adequate electrical outlets <br /> _ _ l'�x''7/1/yi7•�'/`,,��il!!l�/!./i7�p/��7 �! ;� / /! �J, <br /> Signature of Commissa Owner/Operator Date <br /> HEALTH DEPARTMENT_ �4 "� <br /> If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 o 3 MFPU APPLICATION <br /> 7/18/2008 <br />